Recently I have had many questions in my office on when and why I use cartilage grafts for Rhinoplasty or Nasal Reshaping procedures. In this blog I want to explain some of the nuances of grafting. The short answer is–we use grafting in EVERY rhinoplasty procedure, but in some situations different materials may be necessary. As rhinoplasty or nosejob techniques have evolved, we have developed nuances about when we apply grafts and the structure we put into the nose. As we all know, there is no “one size fits all” solution during rhinoplasty. Let’s dive in a bit deeper!
Situations where cartilage grafting maybe necessary…
Open Rhinoplasty
As I mentioned, grafting is used in all rhinoplasty procedures. My technique of choice is typically the open rhinoplasty technique where a small incision is made on the columella or base of the nose. I prefer this approach because it gives the best exposure to perform the procedure and the best visualization. The scar heals very well after several months. However opening the nose can affect the tip support of the nose, and for these reasons grafting is used to provide internal structure to the nose–much like the support beams on the roof of a house.
Revision or Secondary Rhinoplasty
This is an extremely common indication for grafting. If a patient is undergoing a second or third rhinoplasty procedure, grafting is often necessary for structure and in situations of scarring. We use the grafts to build the bridge of the nose, the tip, and the base.
Post-Traumatic Rhinoplasty
In situations of nasal trauma and injury, the bone and cartilage structure can often be destroyed. Here, grafting materials again support the bridge in situations of a “saddle-nose” deformity, or provide projection to the tip.
Rhinoplasty in Asian and African-American Patients
Patients of these ethnicities often require structure for certain aesthetic modifications such as building the bridge of the nose, and making the tip smaller and more defined.
Grafting Materials
Based on the intrinsic qualities, we typically use cartilage from septum, ear, and rib.
Septum
Septal cartilage is from the middle, inner part of the nose and is in my opinion the most natural contour to the nose. Through the rhinoplasty incisions we can carve a piece to use for the procedure. This I do in nearly 100% of my rhinoplasty procedures
Ear
Making an incision in the back of the ear, we can also use this cartilage , which requires a minimal and non-noticeable scar. This cartilage is soft and used for tip grafting mostly.
Rib
Rib is the sturdiest and most robust material use for grafting. It is thick and a large piece can be used for major reconstructive procedures, grafting, and revision surgery. I use this is Asian and African American noses for structure on the dorsum or bridge of the nose. Also, we can use this to add projection and for the best support possible. Obviously the traditional rib grafting requires a separate incision on the chest, usually under the 6th rib (under the breast) for access. It leaves a 4-5 cm scar.
Donor Rib Cartilage
This is a new innovation, which prevents the need for an incision on a patient’s chest. Donor cartilage from companies such as MTF (Musculoskeletal Tissue Foundation) is from a cadaveric donor. It is treated with sterile processes such as antibiotics or radiation to remove any other reactive materials when placed in a patient. It can also come in a pre-cut sheet. This innovation has been helpful in saving surgery time and improving efficiency during rib rhinoplasty.
Rib Cartilage (above is used to rebuild the bridge and tip of nose
Large Onlay rib cartilage placed over bridge of nose (photo from ENT Facial Plastic Surgery Clinic Article 2009 Drs Giancarlo Zuliani and Kailash Narasimhan, MD)
Conclusion:
The rhinoplasty surgeon needs to make the final determination on what material to use, but these grafting regions can be extremely versatile for the difficult case. Dr. Narasimhan has special expertise in major rhinoplasty, revision, Asian rhinoplasty, African-American rhinoplasty, and cartilage grafting techniques. He is board-certified in plastic surgery and otolaryngology. He practices in the Tampa Bay area including Saint Petersburg, Tampa, Clearwater and major Florida cities.
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